October 31st, 2008

A diagnosis of cancer is never good news. Yet, there is good news about cancer detection, treatment – and survival. At Great River Medical Center, two physicians specialize in oncology, the study and treatment of cancer – Rohini Reganti, M.D., and Maroun El-Khoury, M.D.

“It’s challenging now,” Dr. Reganti said. “There are so many new things coming out, and it changes treatments and how you tackle the cancer.”

“Care for a patient with cancer is a multidisciplinary approach,” Dr. El-Khoury said. “The surgeon, the medical oncologist, the radiation oncologist, radiologist, dietitian and social worker come together and develop a plan.

“The incidence of patients with cancer is trending upward,” he said. “We’re seeing 300 to 400 new patients each year.”

With oncology changing rapidly, one notion still needs updating: the name itself – it should be “cancers” – plural.

“Different cancers are different diseases,” said Ingrid Lizarraga, M.D., a general surgeon with Great River Surgeons. “They come about differently, and they’re treated differently.”

“That’s why the oncologist is the captain of the ship,” said Steven Davis, M.D., medical director, Diagnostic Imaging, Great River Medical Center. “They know the potential outcomes for each kind of cancer.”

Early detection is the key to successful treatment
Patients come to Great River Cancer Care Center from throughout the region. Their journey often begins when their family physician finds something wrong.

“We often find cancers when patients come in for screening tests, such as a routine mammogram, a prostate check or a colonoscopy,” said Gary Mansheim, M.D., Burlington Area Family Practice Center. “But sometimes, people have vague symptoms, such as a lump, a fever or a cough. And a problem that appears innocent at first may be hiding cancer.”

Such suspicions lead to laboratory tests or imaging studies for further diagnosis.

“If the patient has a liver lesion, a radiologist uses ultrasound, CT or MRI to guide where our needle’s going to get a tissue sample tissue,” Dr. Davis said.

“General surgeons do biopsies that involve bronchoscopy for lung cancer, colonoscopy for colon cancer or stereotactic breast biopsy,” said general surgeon Michael Niehaus, M.D., Great River Surgeons.

Biopsies produce specimens for study in the Laboratory at Great River Medical Center.

“We look for what kind of cancer it is, where it may have originated and how aggressive it may be,” said Jonathan Snow Jr., M.D., the Laboratory’s medical director.

“After a biopsy has confirmed the diagnosis, the patient usually sees an oncologist, who plans the treatment based on the cancer, its stage and the patient’s general health,” Dr. El-Khoury said.

Mary Knauss, of Burlington, was first diagnosed with breast cancer in 2001. After a lumpectomy, chemotherapy, radiation and more chemotherapy, the cancer went into remission. In 2005 it had metastasized, and she had chemotherapy again.

“That put it into remission again for a year and a half,” she said.

Tom Francis, a retired Burlington orthodontist, was diagnosed with two prostate cancers. His urologist recommended hormone therapy and radiation therapy.

“We would inform their family practice physicians so they know what’s going on with their patients,” Dr. Reganti said.

“Family physicians follow the patient’s other medical problems throughout the treatment process,” Dr. Mansheim said.

Developing a treatment plan
As medical oncologists, Drs. El-Khoury and Reganti oversee the patient’s treatment plan. If it calls for radiation therapy or surgery, they make referrals and monitor the results.

If the plan calls for chemotherapy, they do infusions in their clinic at Great River Medical Center. During the infusion, the patient sits in a recliner, but may move about for refreshments or to visit with other patients. Infusions usually are scheduled three or four weeks apart.

“The first time I had chemotherapy, I asked the nurse if I would feel something,” Ms. Knauss said. “She said, ‘It’s been running for about five minutes.’ Afterward, I thought, ‘I can do this.’”

“Chemotherapy patients can be divided into two groups,” Dr. Reganti said. “If somebody had a cancer, but has a high risk of it returning, we give them adjuvant chemotherapy to help decrease the risk.

“Then you have patients who have become metastatic – the cancer went to another organ. You’re never going to cure them, so your treatments are palliative to manage the symptoms.”

If the treatment plan calls for radiation therapy, the oncologists refer the patient to Great River Cancer Care Center. Physicians from University of Iowa Hospitals provide that service. William McGinnis, M.D., is the onsite radiation oncologist three days each week.

“The first thing I do is take a history and do a physical examination,” Dr. McGinnis said. “Then I develop a treatment plan. We have many national guidelines that we follow.”

“About nine months ago, I started hormone therapy to suppress testosterone, which feeds prostate cancer,” Dr. Francis said. “About four months ago, I started daily radiation for eight weeks.”

Externally delivered radiation therapy at Great River Medical Center uses sophisticated technology. A linear accelerator generates the radiation, computer modeling plots the radiation beams and CT scanning precisely targets the tumor. Intensity-modulated radiation therapy targets the tumor with minimal impact on nearby tissues.

“A computer program written specifically for me tells the machine what dose, how many seconds to give it and what position,” Dr. Francis said. “The machine delivers the radiation from 14 directions. I never feel a thing.”

When cancer treatment requires surgery, many types of specialists may be involved. Urologists, gynecologists and ear-nose-and-throat surgeons each operate on cancers in their areas of specialty. For tumors in other areas of the body, oncologists often call on general surgeons.

“The most common cancers for general surgery at Great River Medical Center are breast, colon and lung,” Dr. Niehaus said. “We’ve been doing laparoscopic resections for colon cancer for some time. It’s less stressful. The patient gets better quicker. And the hospital stay can be shorter.”

Stereotactic biopsy of breast cancer – which uses computer-analyzed X-rays to guide the insertion of the biopsy needle – has eliminated about 90 percent of biopsies that found no cancer. Great River Medical Center was the second hospital in Iowa with a stereotactic biopsy machine.

“Breast cancer has two components,” Dr. Lizarraga said. “The cancer starts in the breast, but it goes to the lymph nodes under the arm.”

“When I started, the gold standard was removal of the breast and two-thirds of the lymph nodes,” said general surgeon John Phillips, M.D. “Now, the same outcomes can be obtained by removing only part of the breast and fewer lymph nodes. It’s a huge improvement for the patient.”

“The standard of care now is the sentinel node biopsy,” Dr. Lizarraga said. “The cancer goes to one lymph node first. If you can find that one lymph node and biopsy it and it’s negative, you know you can leave the rest of the lymph nodes in.”

Some patients need physical therapy after surgery.

“A patient often can have restricted range of motion in the arms after a mastectomy,” said Michelle McDowell, P.T., lymphedema therapist, Great River Center for Rehabilitation. “If they had their lymph nodes removed, they are at risk of developing lymph edema, which can be treated.”

Hospice care for terminal illness
Sometimes, medical science has no more to offer a cancer patient. If so, physicians often refer the patient to hospice care.

“We receive patients by referral,” said Chris Oleson, director of Great River Home Health Care and Hospice. “The physician decides whether the patient meets the key criterion – six months or less to live, if the disease follows its normal course.

“The patient has to choose palliative care, but they want to live the remainder of their lives with as much quality as possible – and that’s what hospice does.”

Most insurances pay for hospice, at least partially, Oleson said. Medicare pays for all hospice caregivers, related medicines and medical supplies or equipment.

At Great River Medical Center, care for patients with most types of cancer compares favorably with hospitals in most large Iowa cities.

“The only cancers we aren’t set up to treat are acute leukemia and brain tumors that require surgery,” Dr. Reganti said.

“I’ve got friends with prostate cancer, and they’ve gone to various places out of town,” Dr. Francis said. “But we’ve got a good team right in our backyard.”